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Crabtree JR, Mulenga C, Tran K, Hussain A, Boente CS, Ali A, Feinberg K, Borschel GH. Corneal Neurotization: Essentials for The Facial Paralysis Surgeon. Facial Plast Surg 2024; 40:424-432. [PMID: 38378042 DOI: 10.1055/a-2272-6077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Deficits in corneal innervation lead to neurotrophic keratopathy (NK). NK is frequently associated with facial palsy, and corneal damage can be accelerated by facial palsy deficits. Corneal nerves are important regulators of limbal stem cells, which play a critical role in epithelial maintenance and healing. Nonsurgical treatments of NK have undergone recent innovation, and growth factors implicated in corneal epithelial renewal are a promising therapeutic avenue. However, surgical intervention with corneal neurotization (CN) remains the only definitive treatment of NK. CN involves the transfer of unaffected sensory donor nerve branches to the affected cornea, and a variety of donor nerves and approaches have been described. CN can be performed in a direct or indirect manner; employ the supraorbital, supratrochlear, infraorbital, or great auricular nerves; and utilize autograft, allograft, or nerve transfer alone. Unfortunately, comparative studies of these factors are limited due to the procedure's novelty and varied recovery timelines after CN. Regardless of the chosen approach, CN has been shown to be a safe and effective procedure to restore corneal sensation and improve visual acuity in patients with NK.
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Affiliation(s)
| | | | - Khoa Tran
- Department of Surgery, Indiana University School of Medicine, Indiana
| | - Arif Hussain
- Department of Surgery, Indiana University School of Medicine, Indiana
| | - Charline S Boente
- Department of Ophthalmology, Indiana University School of Medicine, Indiana
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, Hospital for Sick Children, Toronto, Canada
| | | | - Gregory H Borschel
- Indiana University School of Medicine, Indianapolis, Indiana
- Department of Surgery, Indiana University School of Medicine, Indiana
- Department of Ophthalmology, Indiana University School of Medicine, Indiana
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2
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Serra PL, Giannaccare G, Cuccu A, Bolognesi F, Biglioli F, Marcasciano M, Tarabbia F, Pagliara D, Figus A, Boriani F. Insights on the Choice and Preparation of the Donor Nerve in Corneal Neurotization for Neurotrophic Keratopathy: A Narrative Review. J Clin Med 2024; 13:2268. [PMID: 38673540 PMCID: PMC11050919 DOI: 10.3390/jcm13082268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/28/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials.
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Affiliation(s)
- Pietro Luciano Serra
- Plastic Surgery Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari University Hospital Trust, 07100 Sassari, Italy;
- Plastic Surgery and Microsurgery Unit, Department of Surgical Sciences, Faculty of Medicine and Surgery, University Hospital “Duilio Casula”, University of Cagliari, 09124 Cagliari, Italy; (A.F.); (F.B.)
| | - Giuseppe Giannaccare
- Eye Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy;
| | - Alberto Cuccu
- Eye Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy;
| | - Federico Bolognesi
- Department of Maxillo-Facial Surgery, Santi Paolo e Carlo Hospital, University of Milan, 20122 Milan, Italy; (F.B.); (F.B.); (F.T.)
| | - Federico Biglioli
- Department of Maxillo-Facial Surgery, Santi Paolo e Carlo Hospital, University of Milan, 20122 Milan, Italy; (F.B.); (F.B.); (F.T.)
| | - Marco Marcasciano
- Plastic and Reconstructive Surgery Unit, Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy;
- Unit of Plastic and Reconstructive Surgery, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Filippo Tarabbia
- Department of Maxillo-Facial Surgery, Santi Paolo e Carlo Hospital, University of Milan, 20122 Milan, Italy; (F.B.); (F.B.); (F.T.)
| | - Domenico Pagliara
- Plastic-Reconstructive and Lymphedema Microsurgery Center, Mater Olbia Hospital, 07026 Olbia, Italy;
| | - Andrea Figus
- Plastic Surgery and Microsurgery Unit, Department of Surgical Sciences, Faculty of Medicine and Surgery, University Hospital “Duilio Casula”, University of Cagliari, 09124 Cagliari, Italy; (A.F.); (F.B.)
| | - Filippo Boriani
- Plastic Surgery and Microsurgery Unit, Department of Surgical Sciences, Faculty of Medicine and Surgery, University Hospital “Duilio Casula”, University of Cagliari, 09124 Cagliari, Italy; (A.F.); (F.B.)
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Aujla J, Tong JY, Curragh D, Caplash Y, Chehade M, Tumuluri K, Au A, Low N, Avisar I, Sagiv O, Barequet I, Ben Simon G, Selva D. Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00376. [PMID: 38624152 DOI: 10.1097/iop.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
PURPOSE Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. METHODS Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. RESULTS Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. CONCLUSIONS Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.
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Affiliation(s)
| | - Jessica Y Tong
- South Australian Institute of Ophthalmology
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Yugesh Caplash
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Krishna Tumuluri
- Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney
| | - Alicia Au
- Monash Health Clayton, VIC, Australia
| | | | | | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, U.S.A
| | - Irit Barequet
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
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Saini M, Kalia A, Jain AK, Gaba S, Malhotra C, Gupta A, Soni T, Saini K, Gupta PC, Singh M. Clinical outcomes of corneal neurotization using sural nerve graft in neurotrophic keratopathy. PLoS One 2023; 18:e0294756. [PMID: 38015881 PMCID: PMC10684005 DOI: 10.1371/journal.pone.0294756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy of corneal neurotisation using sural nerve graft coaptation of the contralateral supratrochlear nerve in unilateral neurotrophic keratopathy and corneal anesthesia. Corneal neuralization has emerged as a potential option in the treatment of neurotropic keratopathy, however not free from the predicament. We evaluated the long-term outcome of corneal neurotisation in the treatment of unresponsive unilateral neurotropic keratopathy using surgical variations to mimic and expedient the surgical procedure. METHODS A Prospective interventional study involving patients with unilateral neurotrophic keratopathy (NK) who did not respond to medical measures was conducted. The study parameters evaluated were best-corrected visual acuity improvement, ocular surface evaluation parameters [tear break-up time (TBUT), Schirmer's 1, and ocular surface staining scores (corneal and conjunctival staining)], central corneal sensation (Cochet Bonnet esthesiometer), sub-basal nerve fiber length (SBNFL), and sub-basal nerve fiber density (SBNFD) determined by central confocal microscopy at recruitment and during follow-up at 1-month, 3-month, 6-month, 9-month and 12-month respectively, following corneal neurotization. RESULTS Eleven eyes of 11 patients with unilateral neurotrophic keratopathy (NK) who underwent corneal neurotisation were studied. The mean follow-up was 10.09±2.31months (range, 6-12). Mean best corrected visual acuity in log MAR at baseline, 1.35±0.52 improved significantly to 1.06±0.76 (P = 0.012) at 3 months and continued to 0.55±0.60 (P = 0.027) at 12 months. There was a significant reduction in NK grade severity and improvement in the ocular surface as early as 1 month, and central corneal sensations (P = 0.024) as soon as 3 months. Mean corneal SBNF improved from 3.12±1.84 mm/mm2 to 4.49±1.88 at 1 month (P = 0.008), 13.31±3.61 mm/mm2 (P = 0.028) at 12 months. Mean central corneal SBNFD evident at 6 months was 1.83±2.54no/mm2 (P = 0.018) and 4.90±3.12no/mm2 (P = 0.028) at 12 months. CONCLUSION This study substantiates the routine practice of corneal neurotisation by simplifying the intricacies observed during the procedure.
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Affiliation(s)
- Manu Saini
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Kalia
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun K. Jain
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Gaba
- Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chintan Malhotra
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tanvi Soni
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kulbhushan Saini
- Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parul Chawla Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manpreet Singh
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Daeschler SC, Woo JH, Hussein I, Ali A, Borschel GH. Corneal Neurotization: Preoperative Patient Workup and Surgical Decision-making. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5334. [PMID: 37829104 PMCID: PMC10566830 DOI: 10.1097/gox.0000000000005334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/24/2023] [Indexed: 10/14/2023]
Abstract
Background The use of sensory nerve transfers to the anesthetic cornea has transformed the treatment of neurotrophic keratopathy by restoring ocular surface sensation and activating dysfunctional epithelial repair mechanisms. However, despite numerous reports on surgical techniques, there is a scarcity of information on the interdisciplinary management, preoperative assessment, and surgical decision-making, which are equally critical to treatment success. Methods This Special Topic presents a standardized, interdisciplinary preoperative workup based on our 10-year experience with corneal neurotization in 32 eyes of patients with neurotrophic keratopathy. Results Our assessment includes a medical history review, ophthalmic evaluation, and systematic facial sensory donor nerve mapping for light touch and pain modalities. This approach enables evidence-based patient selection, optimal surgery timing, and suitable donor nerve identification, including backup options. Conclusions Based on a decade-long experience, this special topic highlights the importance of interdisciplinary collaboration and provides a practical roadmap for optimizing patient selection and surgical decision-making in patients undergoing corneal neurotization.
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Affiliation(s)
- Simeon C. Daeschler
- From the SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, Ontario, Canada
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Department of Plastic and Hand Surgery, University of Heidelberg, BG Trauma Hospital, Ludwigshafen, Germany
| | - Jyh Haur Woo
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Singapore National Eye Centre, Singapore, Singapore
| | - Isra Hussein
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Gregory H. Borschel
- From the SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, Ontario, Canada
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Ind
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Su D, Zhang J, Wu Y, Wang W, Wang W, Shao C, Li J. Evaluation of Corneal Nerve Regeneration After Minimally Invasive Corneal Neurotization. Asia Pac J Ophthalmol (Phila) 2023; 12:427-436. [PMID: 37527446 DOI: 10.1097/apo.0000000000000626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023] Open
Abstract
PURPOSE To evaluate the corneal nerve regeneration after minimally invasive corneal neurotization (MICN) and to further clarify the recovery patterns of sensory and trophic functions of the corneal nerves. DESIGN A retrospective cohort study based in the Shanghai Ninth People's Hospital. METHODS Eighteen patients (18 eyes) who underwent MICN for neurotrophic keratopathy due to intracranial surgery was conducted to analyze their follow-up data at 6, 12, 18, and 24 months after surgery. RESULTS At 12 months postoperatively, the growth of the central and peripheral corneal nerve fiber density (CNFD) was 11.47±8.56 and 14.73±8.08 n/mm 2 with subsequent improvement slowing down, and the patient's corneal epithelium defect was healed ahead of the accomplishment of corneal nerve regeneration. The number of dendritic cells also reached its peak. At 18 months postoperatively, the recovery of central and peripheral corneal sensation was 37.22±23.06 mm and 39.38±18.08 mm with no subsequent improvement, and the growth of the central and peripheral corneal nerve branch density (CNBD) was 29.69±11.05 and 43.75±1.41 n/mm 2 , with a positive and significant correlation between corneal sensation and CNBD (at central r =0.632, P <0.005; at peripheral r =0.645, P <0.005). At 24 months postoperatively, mean CNFD, CNBD, and corneal sensation recovered significantly compared with preoperative, but a few patients' corneal sensation recovered insignificantly with good CNFD recovery and poor CNBD recovery. CONCLUSIONS After MICN, the trophic function of the corneal nerve recovers before the sensory function, and in particular, the recovery of sensation is based on the coexistence of the corneal nerve trunk and branches.
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Affiliation(s)
- Dai Su
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jiaying Zhang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Yue Wu
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Wenjin Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunyi Shao
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jin Li
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
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7
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Corneal Neurotization—Indications, Surgical Techniques and Outcomes. J Clin Med 2023; 12:jcm12062214. [PMID: 36983215 PMCID: PMC10059768 DOI: 10.3390/jcm12062214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 03/16/2023] Open
Abstract
Corneal neurotization is a promising surgical approach for the treatment of moderate to severe neurotrophic keratopathy. This technique aims to restore corneal sensation by transferring healthy nerves, either directly or via a conduit, to the anesthetic cornea. This review provides a report on the current state of development, evidence, and experience in the field. We summarize the data available from clinical reports and case series, placing an emphasis on the diversity of the surgical techniques reported. While these data are encouraging, they also highlight the need for a consensus in reporting outcomes and highlight how the next step will involve validating putative outcome parameters when researching and reporting corneal neurotization surgery.
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Saad S, Labani S, Goemaere I, Cuyaubere R, Borderie M, Borderie V, Benkhatar H, Bouheraoua N. Corneal neurotization in the management of neurotrophic keratopathy: A review of the literature. J Fr Ophtalmol 2023; 46:83-96. [PMID: 36473789 DOI: 10.1016/j.jfo.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 12/12/2022]
Abstract
Neurotrophic keratopathy (NK) is a rare degenerative disease in which damage to the corneal nerves leads to corneal hypoesthesia or anesthesia. Neurotrophic corneal ulcers are notoriously difficult to treat and can lead to blindness. Corneal neurotization (CN) is a recent surgical technique aimed at restoring corneal sensation and may offer a definitive treatment in the wake of NK. Herein, we review the surgical techniques utilized in direct and indirect CN. Technical considerations, outcomes, current limitations and future perspectives are also discussed. This article highlights the key points of this promising procedure and biological aspects that will help provide the best treatment options for patients with severe NK.
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Affiliation(s)
- S Saad
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - S Labani
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - I Goemaere
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - R Cuyaubere
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - M Borderie
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France
| | - V Borderie
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France; Sorbonne université, Inserm, CNRS, institut de la vision, 17, rue Moreau, 75012 Paris, France
| | - H Benkhatar
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France; Versailles Hospital Center, Department of Otorhinolaryngology-Head and Neck Surgery, Le Chesnay, France
| | - N Bouheraoua
- CHNO des Quinze-Vingts, IHU FOReSIGHT, Inserm-DGOS CIC 1423, 28, rue de Charenton, 75012 Paris, France; Sorbonne université, Inserm, CNRS, institut de la vision, 17, rue Moreau, 75012 Paris, France.
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Sun S, Lu D, Zhong H, Li C, Yang N, Huang B, Ni S, Li X. Donors for nerve transplantation in craniofacial soft tissue injuries. Front Bioeng Biotechnol 2022; 10:978980. [PMID: 36159691 PMCID: PMC9490317 DOI: 10.3389/fbioe.2022.978980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
Neural tissue is an important soft tissue; for instance, craniofacial nerves govern several aspects of human behavior, including the expression of speech, emotion transmission, sensation, and motor function. Therefore, nerve repair to promote functional recovery after craniofacial soft tissue injuries is indispensable. However, the repair and regeneration of craniofacial nerves are challenging due to their intricate anatomical and physiological characteristics. Currently, nerve transplantation is an irreplaceable treatment for segmental nerve defects. With the development of emerging technologies, transplantation donors have become more diverse. The present article reviews the traditional and emerging alternative materials aimed at advancing cutting-edge research on craniofacial nerve repair and facilitating the transition from the laboratory to the clinic. It also provides a reference for donor selection for nerve repair after clinical craniofacial soft tissue injuries. We found that autografts are still widely accepted as the first options for segmental nerve defects. However, allogeneic composite functional units have a strong advantage for nerve transplantation for nerve defects accompanied by several tissue damages or loss. As an alternative to autografts, decellularized tissue has attracted increasing attention because of its low immunogenicity. Nerve conduits have been developed from traditional autologous tissue to composite conduits based on various synthetic materials, with developments in tissue engineering technology. Nerve conduits have great potential to replace traditional donors because their structures are more consistent with the physiological microenvironment and show self-regulation performance with improvements in 3D technology. New materials, such as hydrogels and nanomaterials, have attracted increasing attention in the biomedical field. Their biocompatibility and stimuli-responsiveness have been gradually explored by researchers in the regeneration and regulation of neural networks.
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Affiliation(s)
- Sishuai Sun
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Di Lu
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Hanlin Zhong
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Chao Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Ning Yang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Bin Huang
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
| | - Shilei Ni
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
- *Correspondence: Shilei Ni, ; Xingang Li,
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital, Cheeloo College of Medicine and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Jinan Microecological Biomedicine Shandong Laboratory and Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
- *Correspondence: Shilei Ni, ; Xingang Li,
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Daeschler SC, Mirmoeini K, Gordon T, Chan K, Zhang J, Ali A, Feinberg K, Borschel GH. Sustained Release of Tacrolimus From a Topical Drug Delivery System Promotes Corneal Reinnervation. Transl Vis Sci Technol 2022; 11:20. [PMID: 35984668 PMCID: PMC9419461 DOI: 10.1167/tvst.11.8.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Corneal nerve fibers provide sensation and maintain the epithelial renewal process. Insufficient corneal innervation can cause neurotrophic keratopathy. Here, topically delivered tacrolimus is evaluated for its therapeutic potential to promote corneal reinnervation in rats. Methods A compartmentalized neuronal cell culture was used to determine the effect of locally delivered tacrolimus on sensory axon regeneration in vitro. The regenerating axons but not the cell bodies were exposed to tacrolimus (50 ng/mL), nerve growth factor (50 ng/mL), or a vehicle control. Axon area and length were measured after 48 hours. Then, a biodegradable nanofiber drug delivery system was fabricated via electrospinning of a tacrolimus-loaded polycarbonate–urethane polymer. Biocompatibility, degradation, drug biodistribution, and therapeutic effectiveness were tested in a rat model of neurotrophic keratopathy induced by stereotactic trigeminal nerve ablation. Results Sensory neurons whose axons were exposed to tacrolimus regenerated significantly more and longer axons compared to vehicle-treated cultures. Trigeminal nerve ablation in rats reliably induced corneal denervation. Four weeks after denervation, rats that had received tacrolimus topically showed similar limbal innervation but a significantly higher nerve fiber density in the center of the cornea compared to the non-treated control. Topically applied tacrolimus was detectable in the ipsilateral vitreal body, the plasma, and the ipsilateral trigeminal ganglion but not in their contralateral counterparts and vital organs after 4 weeks of topical release. Conclusions Locally delivered tacrolimus promotes axonal regeneration in vitro and corneal reinnervation in vivo with minimal systemic drug exposure. Translational Relevance Topically applied tacrolimus may provide a readily translatable approach to promote corneal reinnervation.
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Affiliation(s)
- Simeon C Daeschler
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Kaveh Mirmoeini
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Tessa Gordon
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Katelyn Chan
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Zhang
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Science, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Konstantin Feinberg
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory H Borschel
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Science, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
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11
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Rathi A, Bothra N, Priyadarshini SR, Achanta DSR, Fernandes M, Murthy SI, Kapoor AG, Dave TV, Rath S, Yellinedi R, Nuvvula R, Dendukuri G, Naik MN, Ramappa M. Neurotization of the human cornea - A comprehensive review and an interim report. Indian J Ophthalmol 2022; 70:1905-1917. [PMID: 35647955 PMCID: PMC9359267 DOI: 10.4103/ijo.ijo_2030_21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords “corneal nerves,” “neurotization,” “esthesiometry,” “corneal anesthesia,” and “neurotrophic keratopathy.” All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3–6 months, while nerve regeneration on confocal microscopy can take as long as 6 months–1 year.
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Affiliation(s)
- Anubha Rathi
- The Cornea Institute, KAR Campus; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Nandini Bothra
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | | | - Divya S R Achanta
- The Cornea Institute, KAR Campus; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Merle Fernandes
- The Cornea Institute, KAR Campus, Hyderabad, Telangana; The Cornea Institute, GMRV Campus, L V Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
| | | | - Anasua G Kapoor
- Ophthalmic Plastic Surgery and Aesthetics, Ocular Oncology, KVC Campus, L V Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
| | - Tarjani V Dave
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Suryasnata Rath
- Ophthalmic Plastic Surgery and Aesthetics, Ocular Oncology, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Rajesh Yellinedi
- Basavatarakam, Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Rambabu Nuvvula
- Basavatarakam, Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Gautam Dendukuri
- Ophthalmic Plastic Surgery, Aesthetics and Faciomaxillary Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Milind N Naik
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Muralidhar Ramappa
- The Cornea Institute, KAR Campus; Centre for Rare Eye Diseases and Ocular Genetics, L V Prasad Eye Institute; Jasti V Ramanamma Children's Eye Care Center, L V Prasad Eye Institute, Hyderabad, Telangana, India
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12
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Corneal Neurotization: A Meta-analysis of Outcomes and Patient Selection Factors. Ann Plast Surg 2022; 88:687-694. [PMID: 35502965 DOI: 10.1097/sap.0000000000003117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Corneal neurotization describes reinnervation of the anesthetic or severely hypoesthetic cornea with a healthy local nerve or graft. Preliminary evidence has shown corneal neurotization to improve corneal sensation, visual acuity, and ocular surface health. Factors that improve patient selection and lead to better neurotization outcomes have yet to be elucidated, limiting ability to optimize perioperative decision-making guidelines. METHODS A systematic review with meta-analysis was performed of the MEDLINE and Embase databases using variations of "corneal," "nerve transfer," "neurotization," and "neurotization." The primary outcomes of interest were corrected visual acuity, NK Mackie stage, and central corneal sensation. Regression analyses were performed to identify the effects of surgical technique, duration of denervation, patient age, and etiology of corneal pathology on neurotization outcomes. RESULTS Seventeen studies were included. Corneal neurotization resulted in significant improvement in NK Mackie stage (0.84 vs 2.46, P < 0.001), visual acuity (logarithm of minimum angle of resolution scale: 0.98 vs 1.36, P < 0.001), and corneal sensation (44.5 vs 0.7, P < 0.001). Nerve grafting was associated with greater corneal sensation improvement than nerve transfer (47.7 ± 16.0 vs 35.4 ± 18.76, P = 0.03). Denervation duration was predictive of preneurotization visual acuity (logarithm of minimum angle of resolution scale; R2 = 0.25, P = 0.001), and older age (ß = 0.30, P = 0.03) and acquired etiology (ß = 0.30, P = 0.03) were predictive of improved visual acuity. CONCLUSIONS Corneal neurotization provides significant clinical improvement in visual acuity, NK Mackie staging, and corneal sensation in patients who experience NK. Both nerve grafting and nerve transfer are likely to yield similar levels of benefit and ideally should be performed early to limit denervation time.
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13
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Woo JH, Daeschler SC, Mireskandari K, Borschel GH, Ali A. Minimally Invasive Corneal Neurotization Provides Sensory Function, Protects Against Recurrent Ulceration, and Improves Visual Acuity. Am J Ophthalmol 2022; 241:179-189. [PMID: 35513030 DOI: 10.1016/j.ajo.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To measure sensory recovery after minimally invasive corneal neurotization, and to identify and quantify the extent to which patient and technical factors influence sensory recovery, ulceration rate, and visual outcomes. DESIGN Retrospective case series. METHODS This study included 23 patients with neurotrophic keratopathy who underwent indirect corneal neurotization. The primary outcome measure was corneal sensitivity with Cochet-Bonnet aesthesiometry (CBA), and the secondary outcome measure was epithelial breakdown. RESULTS Over a 7-year period, 28 eyes of 23 patients (mean age, 15.6 ± 13.6 years) were included in the study. The CBA measurements improved from 3.5 ± 9.1 mm at baseline to 44.1 ± 18.2 mm at 24 months after surgery (P < .001). Maximum CBA was reached after 11.1 ± 6.2 months (median, 9 months). Compared to eyes neurotized with a contralateral donor nerve, eyes with an ipsilateral donor nerve achieved a higher mean CBA (36.0 ± 10.9 vs 10.4 ± 14.0 mm, P = .001) at 3 months. Both the number of fascicles (Spearman correlation coefficient, rs -0.474, P = .11) and insertions (rs -0.458, P = .014) negatively correlated with the final CBA. Nine eyes (32.1%) experienced at least 1 episode of epithelial breakdown after surgery. Visual acuity improved in the neurotized corneas from logMAR 0.57 ± 0.79 at baseline to 0.39 ± 0.66 at 12 months (P = .043). CONCLUSIONS Corneal sensation improves over time after corneal neurotization. There is resultant improvement in visual acuity and protection against epithelial breakdown. It is important to maximize sensory recovery to protect against recurrent ulceration.
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14
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Lau N, Osborne SF, Vasquez-Perez A, Wilde CL, Manisali M, Jayaram R. Corneal Neurotization Using the Great Auricular Nerve for Bilateral Congenital Trigeminal Anesthesia. Cornea 2022; 41:654-657. [PMID: 34839333 DOI: 10.1097/ico.0000000000002951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/12/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to describe an indirect corneal neurotization (CN) technique for congenital bilateral trigeminal anesthesia using the greater auricular nerve (GAN) as a donor. METHOD CN was performed to preserve the integrity of the only seeing eye in a 4-year-old boy with pontine tegmental cap dysplasia and bilateral trigeminal anesthesia. He had recurrent corneal ulceration and scarring despite full medical treatment. The GAN was used as a donor, and the sural nerve was harvested and used as a bridge which was tunneled to the sub-Tenon space in the inferior fornix. The fascicles were distributed into the 4 quadrants and sutured to the sclera near the limbus. RESULT This technique resulted in providing corneal sensation and improving stability of the epithelium. Corneal opacity gradually decreased allowing significant visual improvement evidenced in the early postoperative months. CONCLUSIONS Using the GAN technique for CN bypasses trigeminal innervation and has the potential to improve corneal sensation. The GAN is a large caliber nerve and provides a large amount of axons and robust neurotization. This technique would be desirable for cases with bilateral congenital trigeminal anesthesia, such as pontine tegmental cap dysplasia.
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Affiliation(s)
- Nicola Lau
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Sarah F Osborne
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Alfonso Vasquez-Perez
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Caroline L Wilde
- Ophthalmology Department at St George's Hospital, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom ; and
| | - Mehmet Manisali
- Maxillofacial Surgery Department, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Rahul Jayaram
- Maxillofacial Surgery Department, St George's Hospital NHS Foundation Trust, London, United Kingdom
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15
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Kumar A, Yun H, Funderburgh ML, Du Y. Regenerative therapy for the Cornea. Prog Retin Eye Res 2022; 87:101011. [PMID: 34530154 PMCID: PMC8918435 DOI: 10.1016/j.preteyeres.2021.101011] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/13/2022]
Abstract
The cornea is the outmost layer of the eye, unique in its transparency and strength. The cornea not only transmits the light essential for vision, also refracts light, giving focus to images. Each of the three layers of the cornea has properties essential for the function of vision. Although the epithelium can often recover from injury quickly by cell division, loss of limbal stem cells can cause severe corneal surface abnormalities leading to corneal blindness. Disruption of the stromal extracellular matrix and loss of cells determining this structure, the keratocytes, leads to corneal opacity. Corneal endothelium is the inner part of the cornea without self-renewal capacity. It is very important to maintain corneal dehydration and transparency. Permanent damage to the corneal stroma or endothelium can be effectively treated by corneal transplantation; however, there are drawbacks to this procedure, including a shortage of donors, the need for continuing treatment to prevent rejection, and limits to the survival of the graft, averaging 10-20 years. There exists a need for new strategies to promote regeneration of the stromal structure and restore vision. This review highlights critical contributions in regenerative medicine with the aim of corneal reconstruction after injury or disease. These approaches include corneal stromal stem cells, corneal limbal stem cells, embryonic stem cells, and other adult stem cells, as well as induced pluripotent stem cells. Stem cell-derived trophic factors in the forms of secretomes or exosomes for corneal regeneration are also discussed. Corneal sensory nerve regeneration promoting corneal transparency is discussed. This article provides description of the up-to-date options for corneal regeneration and presents exciting possible avenues for future studies toward clinical applications for corneal regeneration.
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Affiliation(s)
- Ajay Kumar
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA 15213
| | - Hongmin Yun
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA 15213
| | | | - Yiqin Du
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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16
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Eleiwa TK, Elhusseiny AM, ElSheikh RH, Ali SF. An Update on Pediatric Corneal Imaging Techniques. Int Ophthalmol Clin 2022; 62:59-71. [PMID: 34965226 DOI: 10.1097/iio.0000000000000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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17
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Brzheskiy VV, Popov VY, Efimova EL, Golubev SY. [Modern capabilities in diagnosis and treatment of neurotrophic keratopathy]. Vestn Oftalmol 2022; 138:123-132. [PMID: 36573956 DOI: 10.17116/oftalma2022138061123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In recent years, the problem of diagnosing and treating neurotrophic keratopathy (NK) has become relevant in view of its prevalence reaching 1.6-11.0 per 10000 people. While previously it was associated only with neuroparalytic keratitis, at present the violation of sensitive and trophic innervation of the cornea with the development of characteristic keratopathy is observed in many diseases and injuries of the organ of vision. Diagnosis of NK is based on anamnestic information and assessment of clinical and functional parameters: determination of the stability of the tear film, tear production and assessment of staining of the ocular surface with vital dyes. The main role in the diagnosis of NK belongs to corneal sensitivity determined with the Cochet-Bonnet esthesiometer. Treatment of NK is designed to restore or increase corneal sensitivity and involves tear replacement therapy, instillations of preparations derived from patient's own blood, anti-inflammatory, metabolic and antibacterial therapy. However, instillations of human erve growth factor (NGF) - the drug Cenegermin (registered in Europe in 2017 at a dose of 20 μg/ml under the name Oxervate), a recombinant form of human rhNGF from Escherichia coli bacteria - exhibit the highest pathogenetic orientation. Its «target» is the affected nerve fibers (specific receptors for their growth factor), which makes it possible to eliminate the violation of reparative processes in neural and epithelial cells. A high and long-term clinical efficacy of a course of six (with an interval of 2 hours) instillations of the drug for 8 weeks in the treatment of children and adults with NK has been established. Among the pathogenetically justified methods of surgical treatment, there is the so-called surgical neurotization of the cornea involving the contralateral supraorbital, supratrochlear, great auricular and other nerves, which has a long-term clinical effect.
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Affiliation(s)
- V V Brzheskiy
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - V Yu Popov
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - E L Efimova
- Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - S Yu Golubev
- Institute of Biomedical Problems, Moscow, Russia
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19
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Gushchina MB, Butsan SB, Salikhov KS, Sergeeva VY. [Treatment of neurotrophic keratopathy in combined lesions of the trigeminal and facial nerves]. Vestn Oftalmol 2022; 138:102-109. [PMID: 35801888 DOI: 10.17116/oftalma2022138031102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ocular symptomatology in lesions of the facial nerve is associated with disturbed innervation of the circular muscle of the eye that leads to disruption of the protective function of the eyelids and the development of exposure symptoms, and is accompanied by a breach in corneal tear film integrity. The main clinical manifestation of the trigeminal nerve damage is the loss of sensory innervation of the cornea and disruption of the supply of neurotransmitters to its cells, manifesting as corneal hypo- or anesthesia. This triggers a cascade of pathological processes that lead to the development of neurotrophic keratopathy. In combined pathology of the facial and trigeminal nerves, a number of interrelated and mutually aggravating problems arise that require correction of lagophthalmos and functional restoration of the trigeminal nerve, since there is an interaction between the corneal epithelium and trigeminal neurons through trophic neuromodulators, which normally contribute to the proliferation of epithelial cells, their differentiation, migration and adhesion, and are essential for vital functions, metabolism and healing of surface lesions of the eye. Classical methods of treating neurotrophic keratopathy aim to protect the ocular surface, and are palliative or auxiliary, do not provide radical relief of the symptoms of neurotrophic keratopathy. Modern surgical technique of neurotization of the cornea allows restoring the structural growth of the nerve, which provides nerve trophism and corneal sensitivity, and is the only pathogenetically substantiated method of effective treatment of neurotrophic keratopathy. At the same time, direct neurotization has undeniable advantages over methods involving intercalary donor nerves, since neuropeptides from nerve fibers are immediately released into the recipient tissue and start reparative processes. Taking into account the accumulated positive experience of neurotization surgeries, scientific and clinical research should be continued in order to improve the most effective methods of corneal neurotization and promote their wider implementation into clinical practice.
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Affiliation(s)
- M B Gushchina
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
- Kaluga branch of S.N. Fedorov National Medical Research Center «MNTK «Eye Microsurgery», Kaluga, Russia
| | - S B Butsan
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
| | - K S Salikhov
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
| | - V Y Sergeeva
- Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russia
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20
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Clinical Outcomes and Patient Satisfaction After Corneal Neurotization. Cornea 2021; 40:1377-1386. [PMID: 34633356 DOI: 10.1097/ico.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 03/10/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to assess clinical outcomes of corneal neurotization (CN) and determine patient perception of postoperative results. METHODS This was a retrospective study involving 29 eyes in 28 patients who underwent CN. Chart review data included demographic and clinical history; ophthalmic examination including visual acuity, ocular surface quality, and corneal sensation; surgical technique; and postoperative course. Subjective self-reported patient outcomes of surgical success were also assessed. Only eyes with at least 6 months of follow-up were included in the statistical analysis. RESULTS A total of 24 eyes and 23 patients were included in statistical analyses. The median postoperative follow-up time was 12.2 months (interquartile range 10.9-18.5 mo). Twenty-three eyes (92%) achieved improvement in ocular surface quality. Eleven of 13 (85%) demonstrated healing of persistent epithelial defects at their last follow-up. Patients gained a median of 2.3 cm in Cochet-Bonnet esthesiometry measurements of sensation. No significant difference was found between preoperative and postoperative visual acuity. All 17 patients who provided self-assessment of their surgical outcome indicated they would undergo CN again if given the choice. Most of the patients reported that the postoperative pain was tolerable, with a median pain score of 3.0 on a 10-point scale (interquartile range 0.0-4.0). Sixteen patients (94%) reported full or partial return of skin sensation along the donor nerve distribution. CONCLUSIONS CN provides improvement in corneal health and sensibility, with high patient satisfaction and minimal postoperative pain and morbidity.
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21
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Vinee F, Grobnicu O, Errera C, Gomart G, Tuzin N, Heitz A, Liverneaux P, Bourcier T. Assessment of Tactile Sensitivity Threshold Using Cochet-Bonnet Esthesiometer and Semmes-Weinstein Monofilaments and Their Use in Corneal Neurotization. Ophthalmic Plast Reconstr Surg 2021; 37:S39-S43. [PMID: 32773513 DOI: 10.1097/iop.0000000000001788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Although the Cochet-Bonnet esthesiometer (CBE) measures corneal sensitivity, it has heretofore only been tested on the index pulp. Tactile skin sensitivity thresholds are measured with Semmes-Weinstein monofilaments (SWM). This study measured skin sensitivity thresholds in healthy individuals using CBE and SWM, and compared both instruments in territories involved in corneal neurotization. METHODS Overall, 27 healthy individuals were tested by a single examiner at 9 territories on the face, neck, forearm, and leg, using 20-thread SWM and CBE with a diameter of 0.12 mm. Both sides were tested. Thresholds were compared for both instruments and between the different territories using Bayesian methods. RESULTS Mean sensitivity levels for SWM ranged from 0.010 to 1.128 g, while mean sensitivity levels for CBE ranged from 0.006 to 0.122 g. Thresholds measured with SWM were significantly higher than with CBE. Both instruments demonstrated higher thresholds in the leg territory than the forearm. However, the forearm presented higher thresholds than the head territories. No significant differences were found between the head territories themselves. Overall, right-side territories exhibited lower thresholds than left-side territories. CONCLUSIONS We have reported the first mapping of skin sensitivity thresholds using CBE. Thresholds measured with CBE and SWM were coherent. The use of CBE on the skin is particularly relevant to the field of corneal neurotization.
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Affiliation(s)
- Frédéric Vinee
- Ophthalmology Department, Strasbourg University Hospital, FMTS
| | - Oana Grobnicu
- Hand Surgery Department, Strasbourg University Hospital, FMTS
| | | | | | - Nicolas Tuzin
- Biostatistics Department, Strasbourg University Hospital, FMTS, Strasbourg, France
| | - Antoine Heitz
- Ophthalmology Department, Strasbourg University Hospital, FMTS
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22
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Corneal Neurotization: A Game-Changing Surgical Procedure for Neurotrophic Keratopathy. Cornea 2021; 41:403-407. [PMID: 33859084 DOI: 10.1097/ico.0000000000002746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study is to describe techniques, results, and open issues of corneal neurotization (CN) for the treatment of neurotrophic keratopathy (NK). METHODS An overview of the most important studies of CN is provided. The 2 main surgical approaches (namely, direct CN and indirect CN) with specific advantages and disadvantages are described. The results regarding changes of corneal sensitivity and clarity, visual acuity, and in vivo confocal microscopy metrics are summarized. Ex vivo studies with histopathology of the neurotized cornea are reported. Intraoperative and early and late postoperative complications are described along with current open issues to be further clarified. RESULTS Corneal sensitivity improves after both direct and indirect CN. Corneal reinnervation allows the healing of NK in almost the totality of the operated eyes, determining a corresponding improvement of corneal clarity and visual acuity. Regeneration of corneal nerve fibers is confirmed by means of either in vivo confocal microscopy or ex vivo histopathology. Few self-limiting complications are reported during the postoperative course. Current open issues concern the identification of the technique of choice, the use of autograft or allograft, and the timing of CN either when performed alone or when combined with other surgeries. CONCLUSIONS CN represents a game-changing surgical procedure for NK, which has the potential to restore corneal sensitivity in all stages of the disease regardless of the mechanism of denervation. Further long-term results are needed to confirm its efficacy over time. The design of randomized clinical trials comparing CN with noninterventional therapies could further validate the adoption of this technique.
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Liu CY, Arteaga AC, Fung SE, Cortina MS, Leyngold IM, Aakalu VK. Corneal neurotization for neurotrophic keratopathy: Review of surgical techniques and outcomes. Ocul Surf 2021; 20:163-172. [PMID: 33647470 PMCID: PMC8113161 DOI: 10.1016/j.jtos.2021.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
Neurotrophic keratopathy is a degenerative disease in which damage to the corneal nerves leads to corneal hypoesthesia. Injuries to neurotrophic corneas are notoriously difficult to treat and have traditionally been approached with supportive management. However, recent progress in the field of corneal neurotization has given new direction for addressing nerve loss directly by stimulating new nerve growth onto the cornea from nearby sensory nerves transferred to the perilimbal region. Herein, we review the surgical techniques utilized in corneal neurotization, including direct transfers and the use of nerve grafts. Considerations in surgical approach, as well as factors that influence prognosis and outcomes of the surgical intervention are also discussed.
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Affiliation(s)
- Catherine Y Liu
- Viterbi Family Department of Ophthalmology, UC San Diego, San Diego, CA, USA.
| | - Andrea C Arteaga
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, College of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Sammie E Fung
- Viterbi Family Department of Ophthalmology, UC San Diego, San Diego, CA, USA
| | - M Soledad Cortina
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, College of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Ilya M Leyngold
- Duke University Medical Center, Department of Ophthalmology, Durham, NC, USA
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, College of Medicine, University of Illinois Chicago, Chicago, IL, USA
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Abstract
Purpose: This review provides an overview of the causes and treatment of neurotrophic keratopathy in the pediatric population.Methods: A thorough review of the current literature discussing neurotrophic keratopathy was conducted then summarized.Results:Fourty-nine papers were reviewed. Congenital and acquired causes of neurotrophic keratopathy exist in the pediatric population. Both medical and surgical approaches to treatment have been trialed, albeit to a limited extent, in pediatric patients. Conservative treatment includes topical lubrication and antibiotics to prevent concurrent infectious ulcer formation. Various neurotrophic factors have been trialed in the form of serum drops to restore corneal sensation when conservative measures fail. Surgically, different corneal neurotization techniques have been developed whereby a donor nerve is routed to the anesthetized cornea to restore innervation and sensation. Conclusions: Advances in the treatment of neurotrophic keratopathy have made corneal reinnervation and restoration of vision more easily attainable in pediatric patients.
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Affiliation(s)
- C Scelfo
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, Boston Children's Hospital, Hawthorne, NY, USA
| | - I S Mantagos
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Clinical and Morphologic Outcomes of Minimally Invasive Direct Corneal Neurotization. Ophthalmic Plast Reconstr Surg 2021; 36:451-457. [PMID: 32032169 DOI: 10.1097/iop.0000000000001586] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe clinical outcomes of a minimally invasive technique for direct corneal neurotization to treat neurotrophic keratopathy. METHODS All cases of corneal neurotization for neurotrophic keratopathy performed by a single surgeon using minimally invasive direct corneal neurotization were reviewed. The supraorbital donor nerve was directly transferred to the cornea through an upper eyelid crease incision using either a combination of endoscopic and direct visualization or direct visualization alone. Detailed ocular and adnexal examinations as well as Cochet-Bonnet esthesiometry of the affected cornea were performed. Corneal histopathology and in vivo confocal microscopy after minimally invasive direct corneal neurotization were reviewed in one patient who underwent simultaneous penetrating keratoplasty. RESULTS Five consecutive cases in 4 patients were included, with a mean follow up of 15.8 months (range: 11-23 months). Average denervation time was 17.8 months (range: 6-24 months). Baseline corneal conditions were Mackie stage 1 (20%), Mackie stage 2 (40%), and Mackie stage 3 (40%). All patients demonstrated improvements in corneal sensibility and appearance postoperatively. All patients demonstrated stable or improved visual acuity. No patients developed persistent epithelial defects postoperatively, and all achieved return of tactile skin sensation in the donor nerve sensory distribution. In vivo confocal microscopy after minimally invasive direct corneal neurotization and simultaneous penetrating keratoplasty demonstrated regeneration of corneal nerves. Complications included an asymptomatic small bony excrescence lateral to the supraorbital notch in one patient and cataract progression in the patient who underwent penetrating keratoplasty. CONCLUSIONS Minimally invasive direct corneal neurotization is a safe and effective treatment of neurotrophic keratopathy.
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Giannaccare G, Pellegrini M, Bolognesi F, Fogagnolo P, Lupardi E, Allevi F, Bernabei F, Lozza A, Plazza C, Marchetti C, Scorcia V, Biglioli F. Spotlight on corneal neurotization. EXPERT REVIEW OF OPHTHALMOLOGY 2021. [DOI: 10.1080/17469899.2021.1895751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Marco Pellegrini
- Ophthalmology Unit, Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy
| | - Federico Bolognesi
- Division of Oral and Maxillofacial Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Paolo Fogagnolo
- Eye Clinic, Head and Neck Department, ASST Santi Paolo E Carlo Hospital, University of Milan, Milan, Italy
| | - Enrico Lupardi
- Ophthalmology Unit, Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy
| | - Fabiana Allevi
- Unit of Maxillofacial Surgery, Head and Neck Department, ASST Santi Paolo E Carlo Hospital, University of Milan, Milan, Italy
| | - Federico Bernabei
- Ophthalmology Unit, Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy
| | | | - Christian Plazza
- Department of Aviation Medicine, Italian Air Force, Milan, Italy
| | - Claudio Marchetti
- Division of Oral and Maxillofacial Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Federico Biglioli
- Unit of Maxillofacial Surgery, Head and Neck Department, ASST Santi Paolo E Carlo Hospital, University of Milan, Milan, Italy
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Corneal Neurotization in the Setting of Facial Paralysis: A Comprehensive Review of Surgical Techniques. J Craniofac Surg 2021; 32:2210-2214. [PMID: 33654040 DOI: 10.1097/scs.0000000000007590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Neurotrophic keratopathy is characterized by decreased corneal sensitivity, decreased reflex tearing, and poor corneal healing resulting in corneal injury. Without proper sensory innervation, the cornea undergoes continuous epithelial injury, ulceration, infection and eventually results in vision loss. In situations where patients have concomitant facial paralysis, such as after resection of a large vestibular schwannoma, the ocular health is further impaired by paralytic lagophthalmos with decreased eye closure and blink reflex, decreased tearing, and potential lower eyelid malposition. In patients with a dual nerve injury, the ocular surface is in significant danger, as there is increased environmental exposure in conjunction with the inability to sense damage when it occurs. Immediate recognition and care of the eye are critical for maintaining ocular health and preventing irreversible vision loss. The first modern corneal neurotization procedure was described in 2009. The ultimate goal in corneal neurotization is to establish sub-basal plexus regeneration via transferring a healthy nerve to the corneo-limbal region. Corneal neurotization can be achieved either via a direct transfer of healthy nerve (direct approach) or via nerve graft interpositions (indirect approach). This is an emerging concept in the treatment of neurotrophic/exposure keratitis and over the past decade multiple direct and indirect approaches have been described in the attempt to restore corneal sensation and to prevent the devastating outcomes of neurotrophic keratitis. Knowledge of these techniques, their advantages, and disadvantages is required for proper management of patients suffering from neurotrophic keratitis in the setting of facial paralysis.
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Direct Versus Indirect Corneal Neurotization for the Treatment of Neurotrophic Keratopathy: A Multicenter Prospective Comparative Study. Am J Ophthalmol 2020; 220:203-214. [PMID: 32659280 DOI: 10.1016/j.ajo.2020.07.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To analyze the comparative safety and efficacy of two techniques of corneal neurotization (CN) (direct corneal neurotization [DCN] vs indirect corneal neurotization [ICN]) for the treatment of neurotrophic keratopathy (NK). DESIGN Multicenter interventional prospective comparative case series. METHODS This study took place at ASST Santi Paolo e Carlo University Hospital, Milan; S.Orsola-Malpighi University Hospital, Bologna; and Santa Maria alle Scotte University Hospital, Siena, Italy. The study population consisted of consecutive patients with NK who underwent CN between November 2014 and October 2019. The intervention procedures included DCN, which was was performed by transferring contralateral supraorbital and supratrochlear nerves. ICN was performed using a sural nerve graft. The main outcome measures included NK healing, corneal sensitivity, corneal nerve fiber length (CNFL) measured by in vivo confocal microscopy (IVCM), and complication rates. RESULTS A total of 26 eyes in 25 patients were included: 16 eyes were treated with DCN and 10 with ICN. After surgery, NK was healed in all patients after a mean period of 3.9 months without differences between DCN and ICN. Mean corneal sensitivity improved significantly 1 year after surgery (from 3.07 to 22.11 mm; P < .001) without differences between the 2 groups. The corneal sub-basal nerve plexus that was absent before surgery in all patients, except 4, become detectable in all cases (mean CNFL: 14.67 ± 7.92 mm/mm2 1 year postoperatively). No major complications were recorded in both groups. CONCLUSIONS CN allowed the healing of NK in all patients as well as improvement of corneal sensitivity in most of them thanks to nerve regeneration documented by IVCM. One year postoperatively, DCN and ICN showed comparable outcomes.
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Sweeney AR, Wang M, Weller CL, Burkat C, Kossler AL, Lee BW, Yen MT. Outcomes of corneal neurotisation using processed nerve allografts: a multicentre case series. Br J Ophthalmol 2020; 106:326-330. [DOI: 10.1136/bjophthalmol-2020-317361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 01/14/2023]
Abstract
BackgroundCorneal neurotisation is a rapidly evolving procedure treating neurotrophic keratopathy. The variety of surgical techniques used and corresponding outcomes after corneal neurotisation are not well understood. This study describes the techniques and outcomes in the largest case series of corneal neurotisation using processed nerve allografts to date.MethodsThis is a retrospective case series of patients who underwent corneal neurotisation with human cadaveric processed nerve allografts. All patients had preoperative and postoperative description of best corrected visual acuity and measurement of corneal sensation. Comparative studies after stratification of techniques were performed.ResultsA total of 17 patients were identified. The cause of corneal anaesthesia was prior infection in eight cases, trigeminal nerve palsy in eight cases and ocular trauma in one case. There were no intraoperative or postoperative complications. Following neurotisation surgery, the time to first gain of corneal sensation and maximal gain of sensation occurred at a mean of 3.7 months (range 1–8 months) and 6.6 months (range 3–15 months), respectively. The mean preoperative and postoperative corneal sensation as measured by Cochet-Bonnet aesthesiometry was 0.36 cm (range 0–3.2 cm) and 4.42 cm (range 0–6 cm), respectively (p<0.01). Visual acuity was unchanged after neurotisation. There were no statistical differences in outcomes based on end-to-end versus end-to-side coaptations, donor nerve selection or laterality of donor nerve.ConclusionCorneal neurotisation with processed nerve allografts is a safe and effective procedure. This study provides further evidence for the use of processed nerve allografts for corneal neurotisation.
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Giannaccare G, Bolognesi F, Biglioli F, Marchetti C, Mariani S, Weiss JS, Allevi F, Cazzola FE, Ponzin D, Lozza A, Bovone C, Scorcia V, Busin M, Campos EC. In Vivo and Ex Vivo Comprehensive Evaluation of Corneal Reinnervation in Eyes Neurotized With Contralateral Supratrochlear and Supraorbital Nerves. Cornea 2020; 39:210-214. [PMID: 31335523 DOI: 10.1097/ico.0000000000002083] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To use an automated morphometric analysis system of in vivo confocal microscopy (IVCM) images for evaluating reinnervation occurring at the subbasal nerve plexus (SNP) after direct corneal neurotization (DCN) and to further report neurophysiological and histopathological findings. METHODS Prospective interventional case series including 3 eyes with neurotrophic keratitis that underwent DCN. Deep anterior lamellar keratoplasty was performed 18 months after DCN in patient 1. The following evaluations were performed before and at 3, 6, and 12 months after DCN: clinical evolution of keratitis; corneal sensitivity; IVCM images of the SNP analyzed with "ACCMetrics;" neurophysiological study of corneal reflex. Protein gene product 9.5 immunofluorescence staining assay and transmission electron microscopy were conducted on the neurotized button excised during deep anterior lamellar keratoplasty. RESULTS Complete healing was obtained in all patients by 3 months postoperatively. Corneal sensitivity was absent preoperatively in all eyes and improved after surgery, reaching an average value of 30 mm 1 year postoperatively. The corneal SNP was not visible at IVCM in any of the cases preoperatively and became visible by 3 months postoperatively, showing IVCM metrics comparable to normal contralateral eyes at 1 year. In all cases, neurophysiological evaluation showed a partial recovery of the electrical activity of the cornea. In patient 1, protein gene product (PGP) 9.5 staining of neurotized cornea showed nerve fascicles at the SNP, whereas transmission electron microscopy showed amyelinic nerve axons and nerve endings. CONCLUSIONS The corneal SNP exhibited IVCM metrics comparable to the normal contralateral eye 1 year after DCN. Ex vivo histopathological assessment of neurotized corneas confirmed the presence of nerves with normal ultrastructure.
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Affiliation(s)
- Giuseppe Giannaccare
- Ophthalmology Unit, DIMES, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy.,Department of Ophthalmology, University "Magna Graecia," Catanzaro, Italy
| | - Federico Bolognesi
- Oral and Maxillofacial Surgery, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Federico Biglioli
- Department of Maxillofacial Surgery, San Paolo Hospital, University of Milan, Milan, Italy
| | - Claudio Marchetti
- Oral and Maxillofacial Surgery, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Silvia Mariani
- Ophthalmology Unit, DIMES, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Jayne S Weiss
- Department of Ophthalmology, Pathology and Pharmacology, Louisiana State University Health Sciences Center, Louisiana State University Eye Center, New Orleans, LA
| | - Fabiana Allevi
- Department of Maxillofacial Surgery, San Paolo Hospital, University of Milan, Milan, Italy
| | - Federica E Cazzola
- Ophthalmology Unit, DIMES, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Diego Ponzin
- International Center for Ocular Physiopathology, the Veneto Eye Bank Foundation, Venice, Italy
| | - Alessandro Lozza
- Service of Neurophysiopathology-National Neurological Institute "C. Mondino," Pavia, Italy
| | - Cristina Bovone
- Department of Ophthalmology, Ospedale Privato "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy; and.,Department of Morphology, Surgery and Experimental Surgery, University of Ferrara, Ferrara, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University "Magna Graecia," Catanzaro, Italy
| | - Massimo Busin
- Department of Ophthalmology, Ospedale Privato "Villa Igea," Forlì, Italy.,Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), Forlì, Italy; and.,Department of Morphology, Surgery and Experimental Surgery, University of Ferrara, Ferrara, Italy
| | - Emilio C Campos
- Ophthalmology Unit, DIMES, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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Werner C, D'Antoni AV, Iwanaga J, Watanabe K, Dumont AS, Tubbs RS. A comprehensive review of the great auricular nerve graft. Neurosurg Rev 2020; 44:1987-1995. [PMID: 33083927 DOI: 10.1007/s10143-020-01426-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/06/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
The great auricular nerve (GAN) is a superficial branch of the cervical plexus that innervates parts of the mandible, auricle, and earlobe. Over the past 30 years, the GAN has become the nerve graft donor of choice for many surgeons for reconstructing injured facial nerves. In this review, we discuss the anatomy and function of the GAN, while focusing on surgical landmarks and the characteristics that make it a suitable nerve graft donor. In addition, we present and summarize published case reports on use of the GAN for grafting. We hope that this review will provide surgeons with an up-to-date and concise reference.
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Affiliation(s)
- Cassidy Werner
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - Anthony V D'Antoni
- Physician Assistant Program, Wagner College, Staten Island, NY, USA.,Division of Anatomy, Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA. .,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan. .,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Koichi Watanabe
- Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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32
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Grusha YO, Novikov ML, Danilov SS, Fettser EI, Karapetyan AS. [Neurotization of the cornea as pathogenically targeted method of treating neurotrophic keratitis in patients with facial paralysis]. Vestn Oftalmol 2020; 136:52-57. [PMID: 33056964 DOI: 10.17116/oftalma202013605152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Combined lesions of the facial and trigeminal cranial nerves are typical after neurosurgical treatment. Violation of the innervation of orbicularis muscle leads to inability to completely close the eyelids, while denervation of the cornea is often manifested as a long-term ongoing and recurring neurotrophic keratitis. The restoration of corneal innervation is a pathogenetically targeted treatment for this pathology. For this purpose, neurotrophic keratitis could be reversed via the method of corneal neurotization using contralateral n. ophthalmicus. The presented clinical case demonstrates the results of the first operation of neurotization of the cornea in a patient with combined lesions of the facial and trigeminal nerves.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, Moscow, Russia.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - M L Novikov
- Clinical emergency hospital named after N.V. Solovyov, Nerve and Paralysis Surgery Center, Yaroslavl, Russia
| | - S S Danilov
- Research Institute of Eye Diseases, Moscow, Russia
| | - E I Fettser
- Research Institute of Eye Diseases, Moscow, Russia.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A S Karapetyan
- Clinical emergency hospital named after N.V. Solovyov, Nerve and Paralysis Surgery Center, Yaroslavl, Russia
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33
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Corneal Neurotization and Novel Medical Therapies for Neurotrophic Keratopathy. CURRENT OPHTHALMOLOGY REPORTS 2020. [DOI: 10.1007/s40135-020-00254-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Purpose of Review
Neurotrophic keratopathy (NK) is a degenerative corneal disease characterized by decreased corneal sensibility and impaired corneal healing. In this article, we review surgical techniques for corneal neurotization (CN) and novel medical therapies for the treatment of NK.
Recent Findings
In recent decades, there has been a paradigm shift in the treatment strategies for NK. New minimally invasive direct and indirect CN approaches have demonstrated efficacy at improving best-corrected visual acuity and central corneal sensation while decreasing surgical morbidity. In addition, several targeted medical therapies, such as recombinant human nerve growth factor (rhNGF), regenerating agents (RGTA), and nicergoline, have shown promise in improving corneal epithelial healing. Of these options, cenegermin (Oxervate®, Dompé), a topical biologic medication, has emerged as an approved medical treatment for moderate to severe NK.
Summary
NK is a challenging condition caused by alterations in corneal nerves, leading to impairment in sensory and trophic function with subsequent breakdown of the cornea. Conventional therapy for NK depends on the severity of disease and focuses primarily on protecting the ocular surface. In recent years, numerous CN techniques and novel medical treatments have been developed that aim to restore proper corneal innervation and promote ocular surface healing. Further studies are needed to better understand the long-term efficacy of these treatment options, their target populations, and the potential synergistic efficacy of combined medical and surgical treatments.
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34
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Guillon-Rolf R, Hau S, Larkin DFP. Clinical and confocal imaging findings in congenital corneal anaesthesia. Br J Ophthalmol 2020; 105:1491-1496. [PMID: 32933933 DOI: 10.1136/bjophthalmol-2020-316672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/29/2020] [Accepted: 08/31/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS Congenital corneal anaesthesia (CCA) is an uncommon cause of corneal ulceration in young patients, with a reported poor visual prognosis. We correlated clinical findings in patients with CCA with corneal sub-basal nerve plexus (SBNP) morphology and dendritiform cell density (DCD) on confocal microscopy. METHODS A prospective, case-control study was conducted at a referral clinic. History includied presenting features in patients with CCA, clinical course and examination findings. Differences in SBNP morphology and DCD on in vivo confocal microscopy (IVCM) were compared in cases and control subjects with healthy corneas. RESULTS Eight patients with CCA were examined, of which three had a diagnosis of familial dysautonomia. Age at initial diagnosis of corneal disease ranged from infancy to 22 years, the most common presentation being corneal ulceration. All patients with CCA except one with optic neuropathy had corrected visual acuity 6/18 (logMAR 0.35) or better in at least one eye. Measured corneal sensation was minimal in all patients. Major abnormalities were found on confocal microscopy in all patients with CCA, whether or not inherited, including statistically significant reduction in SBNP nerve fibre density, fibre length and branch density. Increased DCD in superficial cornea was found in all patients with CCA. CONCLUSION Good visual acuity can be maintained in eyes with corneal anaesthesia present from birth. IVCM provides direct evidence of a morphological correlate for measured corneal anaesthesia. Increased DCD may indicate an enhanced role for innate immune cells in superficial cornea in protection of the anaesthetic ocular surface.
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Affiliation(s)
| | - Scott Hau
- External Diseases Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Daniel F P Larkin
- External Diseases Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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35
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Corneal Neurotization: A Surgical Treatment for Neurotrophic Keratopathy. J Neuroophthalmol 2020; 40:e11-e12. [PMID: 32349065 DOI: 10.1097/wno.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Scarpa F, Colonna A, Ruggeri A. Multiple-Image Deep Learning Analysis for Neuropathy Detection in Corneal Nerve Images. Cornea 2019; 39:342-347. [DOI: 10.1097/ico.0000000000002181] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
The previous treatment options for neurotrophic keratopathy (NK) were limited. Frequently performed surgical procedures for severe NK include amnionic membrane transplantation and tarsorrhaphy. Corneal neurotization describes the transposition of a healthy donor nerve along the limbal circumference to re-establish corneal sensation and trophic function. The nerve transfer can be performed either by directly transpositioning the supraorbital nerve as described here or by using a sural nerve interponate.
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Affiliation(s)
- J N Lueke
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - C Holtmann
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - K Beseoglu
- Klinik für Neurochirurgie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - G Geerling
- Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
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Lateral Antebrachial Cutaneous Nerve as Autologous Graft for Mini-Invasive Corneal Neurotization (MICORNE). Cornea 2019; 38:1029-1032. [DOI: 10.1097/ico.0000000000002004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Wolkow N, Habib LA, Yoon MK, Freitag SK. Corneal Neurotization: Review of a New Surgical Approach and Its Developments. Semin Ophthalmol 2019; 34:473-487. [DOI: 10.1080/08820538.2019.1648692] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Natalie Wolkow
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Larissa A. Habib
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Michael K. Yoon
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Suzanne K. Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Mass Eye and Ear, Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW Neurotrophic keratopathy is a devastating corneal condition that can lead to ocular morbidity and blindness. Current medical and surgical treatments poorly tackle the essential problem of corneal aesthesia and hence fail to provide a permanent cure. Recent advances in corneal neurotization techniques have shown promise to restore corneal nerves in neurotrophic keratopathy. This article aims at reviewing the current surgical advances, along with the current thoughts and evidence available for corneal nerve regeneration. RECENT FINDINGS Corneal neurotization was first introduced in 2009 by Terzis et al., but recently picked up more interest since 2014. Direct and indirect neurotization are being developed, and different nerves (sural nerve, great auricular nerve) have been explored for interposition between frontal nerve branches and the cornea. New endoscopic techniques are introduced for less invasive approaches. On the corneal front, confocal microscopy and esthesiometry studies have established that the regeneration of the corneal nerves is happening 6 months after the procedure. SUMMARY Neurotization is a budding revolutionary technique that shows promise of cure for neurotrophic corneas, but at this stage, it is still reasonably invasive and still reserved for selected patients.
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Minimally Invasive Corneal Neurotization With Acellular Nerve Allograft: Surgical Technique and Clinical Outcomes. Ophthalmic Plast Reconstr Surg 2019; 35:133-140. [DOI: 10.1097/iop.0000000000001181] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Altafulla J, Iwanaga J, Lachkar S, Prickett J, Dupont G, Yilmaz E, Ishak B, Litvack Z, Tubbs RS. The Great Auricular Nerve: Anatomical Study with Application to Nerve Grafting Procedures. World Neurosurg 2019; 125:e403-e407. [PMID: 30703599 DOI: 10.1016/j.wneu.2019.01.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND When it comes to autogenous nerve grafting, the sural and great auricular nerve (GAN) are the 2 nerves predominately used for trigeminal and facial nerve repair. Arising from the second and third cervical ventral rami, the GAN emerges from the posterior border of the sternocleidomastoid coursing superiorly and anteriorly toward the ear. METHODS Eleven sides from 5 Caucasian and 1 Asian cadaveric heads (all fresh-frozen) were used. One man and 5 women were used with an age at death ranging from 57 to 91 years, with a mean of 80.3 years. Measurements were made from the inferior border of the ear to the GAN, the GAN to the external jugular vein, and the inferior border of the mastoid process to the GAN; the proximal, medial, and distal diameters of the GAN and the length of the GAN that was obtained from this exposure were also measured. RESULTS The mean distance from the inferior border of the mastoid process to the GAN, inferior border of the ear to the GAN, and GAN to the external jugular vein was 27.71, 31.03, and 13.28 mm, respectively. The mean length of the GAN was 74.86 mm. The mean diameter of its distal, middle, and proximal portions was 1.51, 1.38, and 1.58 mm, respectively. CONCLUSIONS The GAN is an excellent option for use in nerve grafting for repair of, for example, facial dysfunction. In this study, we review our measurements, techniques for identification, and dissecting techniques for the GAN. The proximity to the operative area and minimal complications associated with GAN grafting might contribute to improved patient satisfaction and better outcomes regarding functional restoration.
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Affiliation(s)
- Juan Altafulla
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Neurosurgery Department, Hospital Santo Tomas, Panama
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington, USA; Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, Japan; Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan.
| | | | - Joshua Prickett
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Graham Dupont
- Seattle Science Foundation, Seattle, Washington, USA
| | - Emre Yilmaz
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Basem Ishak
- Seattle Science Foundation, Seattle, Washington, USA; Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Zachary Litvack
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada
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Jowett N, Pineda II R. Corneal neurotisation by great auricular nerve transfer and scleral-corneal tunnel incisions for neurotrophic keratopathy. Br J Ophthalmol 2018; 103:1235-1238. [DOI: 10.1136/bjophthalmol-2018-312563] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/24/2018] [Accepted: 11/04/2018] [Indexed: 11/04/2022]
Abstract
Background/AimsMedical management of neurotrophickeratopathy is challenging and costly. Supra-orbital nerve transfer to thecornea has proven effective for management of keratopathy, but yieldsconsiderable donor site morbidity. Herein, a novel technique for reinnervationof the anaesthetic cornea is presented and early results characterised.MethodsSensory fibres of the ipsilateral greatauricular nerve were directed via an interposition graft to the anteriorcorneal stroma using scleral-corneal tunnel incisions in two patients withgrade III neurotrophic keratopathy.ResultsImprovements in visual acuity, cornealpachymetry, corneal esthesiometry, and corneal neurotisation as assessed by invivo confocal microscopy were observed within nine months of surgery in bothpatients.ConclusionCorneal neurotisation by interposition grafttransfer of great auricular nerve fibres via scleral-corneal tunnel incisionsappears effective in the management of neurotrophic keratopathy.
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Györi E, Tzou CHJ, Weninger WJ, Reissig L, Schmidt-Erfurth U, Radtke C, Dunavoelgyi R. Axon numbers and landmarks of trigeminal donor nerves for corneal neurotization. PLoS One 2018; 13:e0206642. [PMID: 30379941 PMCID: PMC6209308 DOI: 10.1371/journal.pone.0206642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/16/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose Corneal anesthesia leads to chronic corneal injury. This anatomical study characterizes the donor nerve branches of the supratrochlear and supraorbital nerves used for corneal neurotization. Methods In 13 non-embalmed cadavers, the supratrochlear and supraorbital nerves were dissected and distances to anatomical landmarks measured. Cross-sections of supratrochlear and supraorbital donor nerves were harvested and histomorphometrically analyzed to assess the number of myelinated axons. Results The donor axon counts were 3146 ± 1069.9 for the supratrochlear and 1882 ± 903 for the supraorbital nerve distal to the supraorbital notch. The supratrochlear nerve was dissected on the medial upper eyelid 2 cm lateral to the facial midline and the branch of the supraorbital nerve 1 cm medial to the mid-pupillary line. Conclusion The supraorbital and supratrochlear branches of the trigeminal nerve are potent donor nerves for corneal neurotization in the treatment of neuropathic keratopathy and can be reliably dissected using anatomical landmarks.
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Affiliation(s)
- Eva Györi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Chieh-Han John Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Lukas Reissig
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Ursula Schmidt-Erfurth
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Christine Radtke
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Roman Dunavoelgyi
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
- * E-mail:
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Abstract
PURPOSE OF REVIEW Periocular rehabilitation of the patient with a facial nerve palsy has evolved over time. Although protection of the ocular surface is paramount, application of disfiguring tarsorrhaphies should be utilized only in special situations. The purpose of this review is to discuss current surgical and medical strategies in treatment of the periocular area in patients with facial nerve palsy to give maximal functional and cosmetic results. RECENT FINDINGS Upper lid lagophthalmos is preferentially treated with upper eyelid weights. Platinum has distinct advantages over gold. A supratarsal position of the upper lid weight is preferred over a pretarsal location. Lower lid malposition should be treated as a retraction, rather than an ectropion. Recalcitrant ocular surface disease can be effectively managed with a scleral lens. Tearing in the patient with a facial nerve palsy is often multifactorial; small lumen Jones tubes and botulinum toxin injection to the lacrimal gland should be considered to treat epiphora in these patients. SUMMARY A facial nerve palsy can be devastating for patients from both a functional and cosmetic perspective. Although seismic shifts in treatment of the periocular subunit have not occurred, there are a number of small, yet significant, changes in treatment that should be adopted in taking care of these patients.
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